Medication Adherence Improvement: Challenges & Opportunities
Leah L. Zullig, PhD, MPH Center for Health Services Research in Primary Care Durham Veterans Affairs Medical Center Division of General Internal Medicine Duke University
Disclosures • Veterans Affairs Health Services Research & Development Career Development Award (CDA 13-025) • Pilot Awards: Duke Cancer Institute; Duke Global Health Institute; Duke University O' Brien Center for Kidney Research
4/5 take at least one medication
50%
chronic disease medications are not taken
$318 billion in avoidable spending
Fischer, Michael A., et al. "Primary medication non-adherence: analysis of 195,930 electronic prescriptions." Journal of general internal medicine 25.4 (2010): 284-290. Mahoney, John J., et al. "The unhidden cost of noncompliance." J Manag Care Pharm 14.6b (2008): S1-29. 3 Proprietary and Confidential © Verilogue, Inc. All rights reserved. Express Scripts 2011 Drug Trend Report. Available from: http://digital.turn-page.com/i/70797
Triple Aim of Appropriate Medication Use
Better Population Health Better Individual Health
Better Health Care
Triple Aim of Appropriate Medication Use • More efficient use of public and private resources – Prevention of complications & hospitalizations – Less waste of time & effort
Better Individual Health
Better Health Care
Better Population Health
• Professional, personal, and financial rewards
Defining Medication Adherence
Adherent
Non-Adherent
Types of Medication Non-Adherence
Rx Ordered, But Not Dispensed
Primary
30% of prescriptions are never filled
• Failing to Refill Rx Discontinuation • Refilling Rx to Late • Taking Rx Improperly
Secondary
50%
Persistence
of chronic disease meds Sabate E. 2003. Adherence to Long-Term Therapies: Evidence for Action. WHO. IOM. 2007. Preventing Medication Errors: Quality Chasm Series. National Academies Press. not taken Cramer J, Spilker B. Patient Compliance in Medical Practice and Clinical Trials. New York; 1991:414.
Discontinuation Provider Directed vs.
Patient Directed
Intentional vs.
Unintentional
What we see is not the problem…
Non-Adherence Uninformed Decision-Making Poor Communication
Disengaged Patients Complex Drug Regimens Financial & Cognitive Constraints Mismatched Preferences
…just the tip of hazardous contributing factors.
Mrs. Smith Patient Factors • Financial ability • Time • Cognitive ability • Health literacy • Communication • Social support • Engagement
Mrs. Smith Patient Factors • Financial ability • Time • Cognitive ability • Health literacy • Communication • Social support • Engagement
Clinical Team’s Role • Link to financial assistance • Synchronize Rx refills • Provide reminder tools • Educate about treatment • Counsel & accountability • Suggest peer support • Facilitate self-monitoring
Adherence Improvement Toolbox Reminders Smartphone apps Smart pill bottles Dispenser systems Cuing Literacy interventions Health coaching
Medication synchronization Financial assistance Medication therapy management
Keys to Effective Interventions • Modest effect sizes can be significant if they improve clinical outcomes • A health outcome is the endpoint • No one-size-fits-all intervention • Combinations of 2+ interventions that address different dimensions
Viswanathan, Meera, et al. "Interventions to improve adherence to self-administered medications for chronic diseases in the United States: a systematic review." Annals of internal medicine 157.11 (2012): 785-795.
Limitations of the Evidence • Too small and too short • Limited generalizability • Inadequate evaluation of adverse effects • Poor clinical outcomes assessment • Lack of evaluation of individual components • Limited comparability
Multicomponent Interventions
Educational
Behavioral & Motivational
System Level
Phases of Chronic Medication-Taking Initiation
Implementation
Persistence
Level of motivation
Tailored support
Long-term communication
Readiness for change
Motivational interviewing
Self-monitoring
Self-efficacy
Setting goals
Reinforcement
Problem solving
Cuing
Shared decision making
Vrijens B, De Geest S, Hughes DA, et al. A new taxonomy for describing and defining adherence to medications. British journal of clinical pharmacology 2012;73:691-705.
Is Technology a Delivery Tool? Technology Categories
Specific Solutions
Example Applications
• • • •
Text messaging Smartphone applications Interactive voice response Electronic health records
•
•
•
•
Biometric and physical activity monitors Digital scales
Pill-monitoring Technology
• • •
Electronic pill caps Smart blister packaging Digital pills
• •
Measure adherence objectively Understand patients’ medication taking
Online Resources & Social Media
• •
Web-based peer support Condition-specific online support communities Online self-monitoring
• •
Enable patient self-monitoring Develop patients’ social support system
Mobile Health Technology
Electronic Monitors
•
•
•
Provide tailored feedback to multiple patients simultaneously Deliver timely reminders automatically Collect data between clinic visits to inform decision making Inform patient self-monitoring
Zullig, L. L., Peterson, E. D., & Bosworth, H. B. (2013). Ingredients of successful interventions to improve medication adherence. JAMA, 310(24), 2611-2612.
Challenge of Getting Evidence into Practice System Sustainability 5. Keep the system working
Scalability
Sustainability
4. Spread it system-wide
3. Keep it working
Effectiveness Efficacy
2. Show it works in clinical practice
1. Demonstrate that it works
~17 years adapted from Kellam & Langevin 2003, Balas & Boren 2000
Opportunities for Adherence Work • Policies encourage meaningful use of HIT to engage patients • Financial incentives exist to engage patients • Patient-centeredness is well-supported
http://www.ahier.net/2015/04/stage-3-meaningful-use-and-2015-edition.html
Leah L. Zullig, PhD, MPH Center for Health Services Research in Primary Care Durham Veterans Affairs Medical Center Division of General Internal Medicine Duke University Email:
[email protected] Tel: 1-919-286-0411 ext. 7586 Fax: 1-919-416-5836
